Basic Information
Provider Information | |||||||||
NPI: | 1922361336 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROY | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | IRENE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BROY | ||||||||
OtherFirstName: | KIM | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 5001 STATESMAN DR | ||||||||
Address2: |   | ||||||||
City: | IRVING | ||||||||
State: | TX | ||||||||
PostalCode: | 750632414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8778405157 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5778 CHAPIN ST | ||||||||
Address2: |   | ||||||||
City: | FLORENCE | ||||||||
State: | WI | ||||||||
PostalCode: | 541219443 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7155284833 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2012 | ||||||||
LastUpdateDate: | 10/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | LL00003739 | WA | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | 15670 | CA | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | 1834-154 | WI | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.